248- Back Surgery vs Chiropractic- What Does the Science Say

Welcome to the Evidence Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now, here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid, and today we are diving into the research in what is probably one of my favorite studies. It's something I dove back into building the Smart Chiropractor monthly content campaign for October, which is all about lumbar spine and low back. And the study that I happened upon was Manipulation or Microdiscectomy for Sciatica. It's a study I've highlighted, but I think it's been a couple years and this is one that I think is incredibly important to not only be aware of, but but to understand the implications and how you can utilize this to further position yourself in your community. So that's where we're gonna dive into today. Before we get started, if you have not left a reading, review or feedback on itunes for this podcast, I'm gonna please ask you to do so. If you're listening on your iPhone, you can scroll on down and tap how many stars you'd like to give the podcast. It helps more and more docs find out about the podcast and it helps more tune in and listen. Itunes sort of favors things when it sees that there's a bunch of engagement and a bunch of ratings or reviews. So if you could do that, I would greatly appreciate it. Thank you so much for tuning in week after week. And without further ado, let's dive into this week's topic and this week's research. As I said at the top, the title is Manipulation or Microdiscectomy for Sciatica. I'll put it in slightly different terms. Chiropractic care or Surgery for Sciatica. That's what they're really breaking down here. If you'd like to check out the study itself, scroll on down in the show notes and you'll see a direct link there. So as chiropractors, we see patients all the time that have sciatica. Now, true sciatica and what people typically describe as sciatica, as we know, two wildly different things, right? True sciatica happens at L5S1 exclusively. It's pain that goes all the way down into past the ankle, into into the foot. A lot of times people have L4L5 issues that are hitting their calves and they're calling that sciatica. So there's a little bit of discrepancy there, but bottom line is L5S1 is true sciatica and the prevalence of sciatica caused by lumbar disc herniation. Right. Three things that can pinch or compress a nerve historically. Disc, bone or ligament. Disc herniation causing sciatica. Lifetime incidence between 2 to 40%. That's not a huge range. I don't know what is. You have a 2 to likelihood of having a disc herniation cause sciatica at some point in your life and at any given time. So we sort of call it prevalence. Right. What's going on at any given moment, you know, 5.1% of men, 3.7% of women older than 30 years old have disc herniations causing sciatica. So it's a lot of people, right? You think about a town of a hundred thousand people, 5% of men, 5,000 men have that going on. In a town of a town of a hundred thousand, almost 4,000 women at any given given time. I got a feeling that's enough to fill up your waiting room for sure. So this is an issue that you need to know how to communicate and you certainly need to know the science behind it. So researchers in this study estimate that non operative management has been demonstrated to be beneficial in more than 50% of patients with sciatica. So it's a good start, right? Over half the number of people that come into a chiropractic clinic, or any non operative management for that matter, will end up being able to avoid surgery because they will have significant benefits. Benefit. Now why is that important? Well, let's put a juxtaposition to the other side. Elective dissectomies are one of the most commonly performed surgical procedures in the United States. It's like way over a quarter million cases each and every year. I'd probably estimate that it's closer to half a million. Now this study is about 8, 9 years old, 10 years old. So I'd estimate that that has only increased over time as, as there's been more scrutiny on fusions. Infusions were topping, you know, hundred, I think over, you know, hundreds of over 500,000 per year. So disectomies might be neck and neck with the fusions at this point in time, I'm going to say. But bare minimum, we're talking 250,000 elective keyword there, elective disc. So not, not, not emergency elective disc surgeries per year. So that's pretty stunning, right? That's a Lot of individuals. And a lot of individuals, based upon the research and what we'll dive into on today's episode, that really should be in your practice, you know, and we'll talk through that in a moment. So previous studies, Cassidy and colleagues reported clinical improvement in 50% of their study sample in a series of case studies with chronic sciatica treated with manipulation. So going back to that non operative management, again, we're looking at 50% plus of individuals who have sciatica. Probably gonna have a really, really good result in your practice. If I asked you what percentage of, you're probably gonna tell me 75 to 85% of the people that come in with sciatica end up seeing significant improvement. And I don't think that you would be lying if you told me that time and time again. We see sciatica respond exceptionally well in chiropractic clinics. So let's talk about the research. Let's break it down. They basically had two big arms of this study, right? Those that underwent adjustment, spinal manipulation, and those that underwent a surgical microdiscectomy. So how does this lay out? Well, treatments typically require two to three visits per week for the first four weeks, reducing to one to two visits per week for the next three to four weeks. So that was kind of the treatment frequency. At the eight week mark, follow up visits were scheduled based upon symptomatology. So at that point they might have broken down to wider or closer visits depending upon what was going on with the patient's symptoms. So from a care perspective, on the chiropractic side, that's what was going on. On the surgical side, laminotomies were created at the level of lumbar disc herniation and any of the sequestered disc and or any of the intraannular issues were cleaned out and that surgery was performed for adequate nerve root decompression. So they tried to use minimally invasive techniques as far as this study is concerned. So this was not old school. This was utilizing what they refer to as microsurgical techniques. Probably what we'd call minimally invasive today. So small incision at the level you remove a piece of the lamina to gain access via the posterior column in, into the central canal. Now you have to approach, when you do a posterior spinal surgery, you do approach at an angle because you have to be able to peek around, so to speak, the spinal cord or the cauda equina to get to the backside of the disc, which if you're in a posterior approach, of course is in front of the spinal cord. So you have to have a little bit of an angle there to make sure that you can grab the material. Thankfully, most disc herniations are, you know, posterior lateral. So there is a lateral component to the disc. That's where we get one sided symptomatology because it's encroaching upon one of the IVFs. Central disc herniation is a little bit more difficult to take care of because it's just difficult to peek around the spinal cord. Actually, it's nearly impossible to address a central, a true central disc herniation in the cervical spine from a posterior approach in the lumbar spine. There's more room, there's a little bit more give, but just some background there on the, on the surgery itself. So, you know, with the spinal manipulation group, the average number of visits was 21 visits and then six rehab sessions over a year long period. So the average number of visits was about 21 patients in the surgical group, single procedure followed by six rehab visits over that year long. So when we looked at it from a year, about 21 patient visits that went to the chiropractor, single surgery, of course, with about six rehab visits after that. So that's how things broke down. Now let's get into the results. Number one, it's well established that the failure rate for microdiscectomy in the relief of radiculopathy secondary disc herniation is up to 20%. So up to 20% of individuals, this is like, it's pretty wild to me. Up to 20% of individuals that are going to get this quote unquote, and we know it, we've taught, we've heard patients say this before, they're going to get it quote unquote fixed, as if surgery is some sort of permanent fixed. It's just not, it's just not the way it is. I don't know where people get that from, where that myth was stemmed from. But the bottom line is up to 20% of individuals with microdiscectomies fail over time. So I mean, it's not an absolute fix by any stretch of the imagination. Now this study found by intent to treat analysis that a relatively high number, 60% of patients failing initial medical management and deemed appropriate for surgical intervention can gain a similar amount of pain relief through spinal manipulation as they might have gained from surgery. Yes, I did not read that incorrectly. That is the truth. And that is the big take home message. 60% of people who failed initial medical management, so they failed some physical therapy. They might have taken NSAIDs, and that not worked. Again, a lot of people, and I'm just going to say it how I've seen it time and time again. And I practiced in multiple multidisciplinary type groups, multiple surgery groups. You know, I've just seen it happen time and time again where it's, oh, you went for six visits of pt, I guess you checked the box for conservative care and that didn't work. Oh, you took two weeks of NSAIDs, as if that was going to do anything for a structural issue anyway. It's not, oh, well, you checked the box for conservative care. Looks like surgery is your next best option, or at least injections. And this study just shows that that is patently false. 60% over half of the individuals who failed initial medical management, meaning they did not go to chiropractic care, but they went to nsaids, they went to some therapy, they did these other things, and they were qualified at that point as surgical candidates. 60% of them benefited from chiropractic spinal manipulation to the same degree as if they would have underwent surgery. That is incredibly impactful. And now let's take that even one step farther, which gets even more wild. In the present study, patients who failed chiropractic care, spinal manipulation, went on to surgical decompression, ultimately benefited in a real big way. And there was no delay in the treatment. There's no adverse effect of the delay in treatment. So this is really, really important. It basically showcases. I'll phrase this a different way. I'm gonna say it again as we get into some of the quotes. It basically showcases there is almost no reason in a non emergent situation that a patient should not be going through a course of chiropractic care before going through a surgical procedure. Because if they even fail what you do, if they're not able to get any results, they start sliding downhill. They're just not able to get those gains and benefits. It stands to show, based upon this study, that they're actually great candidates for surgery and there's no negative effect of that delay. Absolutely incredible, absolutely impactful. And I don't think anybody knows about this study, but I'm glad you're listening because now you do. So it also. I'll get to take it one more step further, quote unquote. Finally, it appears that those patients who fail surgery do not benefit from further spinal manipulation intervention. So this is not something necessarily that goes both directions. Those individuals in this study who failed surgery then went back to the chiropractor, it's tough going Right. The anatomy's been changed. Surgery is a permanent, irreversible change to a person's body. And it is much more difficult, not impossible. We've all seen post surgical patients who have done very well with our care, I'm sure, but it's not impossible. But in this case, it doesn't go both ways equally. In other words, it's not something where, well, let's just try the surgery then if you fail, just go to the chiropractor. No, this needs to be thought of in the opposite way. It needs to be reinforced in the opposite way. And their conclusion was most of the patients who are considered surgical candidates for the treatment of radiculopathy from lumbar disc herniation improve with standardized spinal manipulative care to the same degree as those who had undergone surgery. Of those who failed spinal manipulation treatment, subsequent surgical intervention provided excellent outcome. End quote. Take home message. This is something that's impactful. It's affecting hundreds of thousands. I mean, when we look at the number of people affected by sciatica, we're looking in the tens of millions each and every year. We look at the numbers of individuals undergoing elective surgeries with a 20% failure rate, we're looking at hundreds of thousands of people per year. In getting this information out, we featured this previously in a couple of years back as a piece of the evidence based chiropractor to be able to bridge the gap and build relationships with primary care physicians in your community. Not in a way that's disparaging surgery in any way, shape or form whatsoever, but in a way that opens the eyes to the actual process and recommendations based upon clinical guidelines and best practices. That starts to become incredibly impactful. If you didn't know about this study previous to this podcast, I'm gonna go out on a limb and say there is hardly a, there are hardly any. There are zero primary care physicians in your community who know about this study. So get out there, share the information if you want to build those relationships at the most effective, highest level and in the easiest way possible. We've done it with hundreds of docs around the world. Literally. Head over to the smart the evidencebasedchiropractor.com now. Smart chiropractor. As I was saying, if you want to utilize this sort of information for your community, if you want to have content, campaigns, monthly campaigns, weekly topics, daily posts, emails in office video, all of that automated for you, research based, then head out over to thesmartchiropractor.com October is going to be lumbar spine month. We're featuring this study as well as a host of other really, really incredible things that's going to be able to open the eyes of the people in your community, get more people coming in, reactivate more patients. That's what we do. And Evidence Based Chiropractor, it's all about B2B business to business, you building relationships with other healthcare providers. The smart Chiropractor is all B to business to consumer, you generating patience for your practice from the people in your community. Both are exceptionally important pieces of building a sustainable, growing, stable chiropractic practice. It's just a matter of which one you want to focus on, at which point. And I have many, many docs that I work with in both programs simultaneously because they are trying to get absolute best results. So if you have any questions about this whatsoever, feel free to hit me up. Jeff the evidencebasedchiropractor.com Check out this research study by clicking through in the show notes. Please leave us a or review for this podcast if you have not done so. And if I can help you with the Evidence Based Chiropractor or the Smart Chiropractor, head on over those respective pages. Get started and I'll look forward to hearing from you soon. Have a fantastic week in practice and I will talk to you soon.

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Sam.